Basic Information
| Provider Information | |||||||||
| NPI: | 1528054947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYES | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | ROEL | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4131 W LOOMIS RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532212059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143257246 | ||||||||
| FaxNumber: | 4143253770 | ||||||||
| Practice Location | |||||||||
| Address1: | 4448 W LOOMIS RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532204800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143257246 | ||||||||
| FaxNumber: | 4143253770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2005 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 222707 | MA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | DO1620 | NV | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | 222707 | MA | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207LP2900X | 68268-21 | WI | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2083035 | 05 | MA | MEDICAID |